The Use of Psychedelic Agents with Autistic Schizophrenic Children

Robert E. Mogar & Robert W. Aldrich

from Psychedelic Review
Number 10, 1969

Evidence from seven independent studies indicates LSD
may help free the most severely imprisoned minds.

In recent years, a number of exploratory investigations have
been reported involving the administration of psychedelic agents
to young children suffering from severe forms of psychological
disturbance (Abramson, 1960; Bender, et al., 1962; Bender, et
al., 1963; Fisher & Castile, 1963; Freedman, et al., 1962;
Rolo, et al., 1965; Simmons, et al., 1966). As either therapeutic
or experimental undertakings, these studies are extremely
fragmentary and suffer gross shortcomings. As a case in point,
wide diversity along major dimensions known to influence drug
response and treatment effectiveness characterize this work.
These include the agent employed, dosage level, number and
frequency of administrations, therapist expectations and previous
experience with psychedelic drugs, and finally the setting and
circumstances surrounding the drug-induced state. With regard to
patient characteristics, the children treated were
demographically varied and covered a broad age range. More
importantly, the samples were markedly heterogeneous with respect
to the nature, severity, and duration of modal symptoms. The
major experimental shortcomings included small samples,
subjective and vague criteria of drug effects and improvement,
and grossly inadequate follow-up.
Despite their diversity and severe limitations, these seminal
explorations in an extremely complex area of research seem worthy
of wider reportage and more serious attention than they have
hitherto received. Almost without exception, these reports have
appeared in obscure publications or remain unpublished. A more
significant reason for their relative neglect has been the
polarized controversy surrounding psychedelic agents which has
all but completely curtailed publicly-sanctioned research.
In this critique of the use of psychedelic agents with
severely disturbed children, the various studies conducted thus
far will be comprehensively reviewed and integrated. Particular
attention will be given to their similarities and differences
along known relevant dimensions in order to detect communalities
and possible reasons for inconsistent findings. While some
attempt will be made to resolve seemingly contradictory results,
the heuristic value of this work will be emphasized rather than
its conclusiveness . Hopefully, the tentative conclusions derived
from these initial efforts will point the way for more definitive
studies into the therapeutic efficacy of psychedelic agents with
childhood disorders.

PATIENT CHARACTERISTICS

A fairly exhaustive search of clinical and research reports
revealed a total of 91 severely disturbed children who have been
administered one or more psychedelic agents for experimental
and/or therapeutic purposes. As detailed in Table
1, this collective group of patients ranged from five to
fifteen years of age, with the large majority between six and ten
years of age. Careful examination of the seven independent
studies disclosed little basis for assuming a significant
relationship between age and drug response. However, tentative
relationships were suggested by both Bender (1963) and Fisher and
Castile (1963). Bender noted that in contrast to pre-
adolescents, younger children manifest consistently different
reactions to a variety of medical and pharmacological treatments.
For this reason, she hypothesized that her older patient group
(12-15, N = 8) would not show the dramatic positive changes
obtained with the younger children. Contrary to expectations,
comparable favorable effects were found irrespective of age
differences. Fisher and Castile, on the other hand, concluded
that older children were better candidates for psychedelic
therapy because verbal communication was possible and also
because they tended to be less withdrawn, more schizophrenic than
autistic, and displayed more blatant symptomology. While these
patient features were obvious advantages for the particular
therapy technique employed by Fisher and Castile, it is unlikely
that this symptom picture consistently distinguishes older from
younger psychotic children. Thus, on the basis of the available
evidence concerning the immediate and subsequent effects of
psychedelic drugs on children, age per se appears to be an
inconsequential variable.
All of the patients treated in these studies were described as
severely and chronically disturbed with a primary diagnosis of
autism or childhood schizophrenia. With regard to duration of
illness, most had been hospitalized for periods ranging from two
to four years. Many were afflicted since birth. An apparent
exception was the single patient studied by Rolo and his co-
workers (1965). This twelve year old boy had been hospitalized
for four months. No estimate of the duration of his illness was
reported. At the opposite extreme, the twelve children treated by
Fisher and Castile were probably the most severely disturbed with
an average illness duration of 7.6 years.
The modal symptoms characterizing the majority of children
given psychedelic treatment were well summarized by Simmons and
his coworkers (1966): (1) preoccupation with and stereotyped
manipulation of objects (toys, etc.); (2) isolation of the self
from contact with animate objects (including minimal eye
contact); (3) failure to acquire general social behaviors
(including speech); and (4) bizarre rhythmic repetitive motor
patterns. This syndrome conforms closely to the classical picture
of infantile autism (see e.g., Rimland, 1964). As suggested
earlier, the symptoms picture of the older children treated by
Bender and by Fisher and Castile resembled adult schizophrenia
more than infantile autism. This was also true of Rolo's single
patient. Although autism was invariably present, the
"schizophrenic" children were less withdrawn and
manifested a greater variety of symptoms including overt
aggression, hallucinations, paranoid delusions, and psychosomatic
disturbances. Almost without exception, long-standing mutism was
characteristic of all 91 patients prior to psychedelic treatment.
Despite these significant communalities among the seven groups
of children studied, individual differences in patient
characteristics extended over a fairly broad range. Without
discounting the possible importance of individual differences,
there is little indication in the work reviewed here of
differential response or benefit as a function of age, diagnosis,
duration or severity of illness. As will become apparent in
subsequent sections of this paper, the failure to detect such
relationships seems partlydueto fragmentary patient data and the
crude estimates available of drug response and subsequent changes
in behavior. Consistent with this hypothesis, the differential
findings reported by Fisher and Castile appear to reflect their
more detailed assessment of personal history information and
individual differences in both pre- and post- treatment
symptomology. They also applied more stringent criteria of
improvement than the other investigators.

RATIONALE AND HYPOTHESES

Explicit hypotheses or theoretical bases for administering
psychedelic drugs to disturbed children are almost completely
absent in these exploratory studies. The lack of a definite
rationale is hardly surprising when one considers the enigma
surrounding both schizophrenic behavior in children and response
to psychedelic drugs. Despite great diversity in expectations
andtechnique,there was one point of departure shared by all
investigators, namely, that all known forms of treatment had been
attempted without success. Thus, the use of a potent experimental
drug with the particular chronic patients selected seemed
justified.
With regard to the purpose of these studies, all were to some
extent exploring the therapeutic potential of psychedelic drugs
rather than their psychotomimetic properties. This was least true
of Freedman and his coworkers (1962) who viewed LSD primarily as
a means of studying the schizophrenic process by
"intensifying pre-existing symptomology." This
orientation contrasted sharply with Bender's view. Noting that
withdrawn children became more emotionally responsive while
aggressive children became less so, she hypothesized that
psychedelic drugs "tend to 'normalize' behavior rather than
subdue or stimulate it." This basic difference in
expectations seems at least partially responsible for Bender's
extremely favorable outcomes and Freedman's rather poor results.
Regarding all forms of psychotherapy, it has become a truism that
" where there is no therapeutic intent, there is no
therapeutic result" (Charles Savage in Abramson, 1960, p.
193).
Consistent with their explicit therapeutic intent, Bender,
Fisher, and Simmons each offer essentially the same hypothesis
based on a psychological interpretation of childhood
schizophrenia: " The working hypothesis of this study is
that the psychosis is a massive defensive structure in the
service of protecting and defending the patient against his
feelings and affectual states" (Fisher & Castile, 1963).
Psychedelic drugs were viewed as a powerful means of undermining
an intractable defense system and thereby making the patient more
receptive to contact and communication with others. In attempting
to explain the predominantly positive results in this area of
research (see Table 1), it is worth emphasizing that the
collective work of Bender, Fisher, and Simmons accounts for over
75 per cent of the 91 children treated with psychedelic drugs.
Although their techniques differed considerably, these
investigators shared a psychological conception of autistic
symptoms and a psycho-therapeutic orientation to drug treatment.
Although Freedman was prompted to use LSD primarily as an
experimental device to study psychosis, he did mention that he
was influenced to some extent by the dramatic improvement in
autistic children reported by Peck and Murphy (in Abramson, 1960)
and by the apparent success of Cholden, Kurland, and Savage
(1955) in their work with adult mute catatonic patients. As will
become apparent in the discussion of results, a partial and often
transient alleviation of mutism by LSD treatment has been one of
the most consistent effects reported in the children studies.
A final secondary objective worth mentioning is that the more
recent studies (Rolo, et al., 1965; Simmons, et al., 1966) were
influenced by Bender' s earlier reports of successful LSD
treatment. These studies were attempts to replicate Bender's
findings using various control measures and other methodological
refinements.

DRUG REGIME

As indicated in Table 1, LSD-25 has been by far the most
frequently employed psychedelic agent in work with psychotic
children. An exception was Benders s second study (1963) in which
she gave one-half of her patients LSD-25 and the other half UM
L491. The experimental drug UML-491 was described as a more
potent serotonin inhibitor without the psychedelic properties
associated with LSD-25. Based on a variety of biochemical indices
and observations of differential behavior changes, Bender
reported no apparent differences between the action or
effectiveness of the two drugs.
Fisher and Castile employed LSD-25 and psilocybin at times
singly and at times simultaneously. These investigators were
unique in using a variety of dosage leveldrug combinations both
with the same patient on different occasions and with different
patients on the same occasion. The specific drug regime adopted
for a given session was determined by clinical criteria of the
patient' s particular defense structure and his expected
resistance to psychedeliedrugs. Stated differently, Fisher and
Castile were the only investigators who attempted to optimize the
psychedelic experience for a given patient rather than
mechanically administering a constant dosage of the same agent to
all patients. This feature of their method was consistent with
the greater attention paid to individual patient differences and
their general orientation to psychedelic therapy as a
psychopharmacological process .
Concerning dosage level, most investigators settled on 100
micrograms as optimal. Although this was the average dosage used
by Bender, she differed from the others by starting treatment at
a relatively low level (50 mcgs.) and gradually increasing the
amount to as high as 150 mcgs. As suggested earlier, Fisher and
Castile usually administered multiple agents and employed a wide
range of dosage levels (with LSD, 50 to 400 mcgs.). As their work
progressed, they developed a definite preference for the
prolonged high dose psychedelic experience, especially with older
schizophrenic children. Their most effective results were
obtained with pre-treatment medication of 10 mg. Librium, 10 to
15 mg. of Psilocybin given approximately one-half hour later,
followed by 250 to 300 mcg. of LSD administered twenty minutes
later. In addition, Fisher and Castile often gave
"boosters" during the session itself ranging from 25 to
100 mcg. of LSD. Boosting was considered beneficial " (a)
when the patient seemed to be caught up in a problem area which
he could not break through; (b) when the patient kept defending
himself from new experiences; (c) when the patient increased his
defensive, stereotyped behavior and the psychotic controls became
intensified."
With regard to frequency and total number of treatments, the
seven studies varied widely ---from Freedman's single session per
patient to Bender's daily sessions over periods as long as one
year. Although more frequent and prolonged treatment was often
impossible for non- clinical reasons, Fisher' s group averaged
five sessions per patient given preferably at two week intervals.
With both Rolo' s single patient and Simmons' pair of identical
twins, experimental requirements precluded an optimal therapeutic
regime. Both investigators attempted double-blind procedures and
more objective observational methods. Rolo administered 100 mcg.
LSD on 28 consecutive days while Simmons gave a total of nine 50
mcg. LSD treatments, approximately two per week, interspersed
with inert placebo sessions and control (no-drug) trials.
After citing extensive evidence indicating rapid tolerance of
LSD-25, Freedman concluded that repeated administrations would be
ineffective with psychotic children. Bender, on the other hand,
found little indication of either rapid or sustained tolerance to
LSD using her method of continued daily adrninistrations over
extended periods. With her relatively large group of patients,
Bender did observe a leveling off of reactivity after several
weeks or months of uninterrupted treatment. She considered it
unlikely, however, that this effect was due to physiological drug
tolerance. The impressive improvement rates obtained by Bender in
contrast to Freedman's results offer support for a high frequency
regime of moderately large doses. It is worth noting that Fisher
and Castile arrived at a similar conclusion without knowledge of
Bender's work. Parenthetically, the significance of a possible
drug tolerance effect is further lessened by the findings of more
recent experiments indicating that tolerance to LSD diminishes
almost as rapidly as it develops (Hoffer, 1965) .

PHYSICAL AND PSYCHOLOGICAL MILIEU

It should be emphasized that the findings obtained in these
studies are the result of an interrelated set of determinants,
only one of which is the ingestion of a particular chemical
agent. The significance of seemingly contradictory results has
often been obscured by the persistent search for static, "
drug-specific" reactions to LSD. Inconsistent findings
become more understandable if the psychedelic experience is
viewed as a dynamic configuration of intimate patient
therapist-milieu transactions. In short, the administration of
LSD is inextricably embedded in a larger psychosocial process
which should be optimized in accordance with particular treatment
goals.
Even a cursory examination of the work with autistic children
clearly reveals that at least some important aspects of the
physical and psychological milieu were considerably less than
optimal. In the seven studies reviewed here, only Fisher and
Castile attempted to create a specifically non-medical atmosphere
that was minimally threatening to the patient. Modeled after the
widely-adopted Saskatchewan technique (Blewett & Chwelos,
1959; Hoffer, 1965), the procedure developed by Fisher and
Castile included the following key features: (1) a high dose, 7
to 10 hour session; (2) the use of a variety of
therapeutically-meaningful or aesthetically- pleasing stimuli
(music, flowers, pictures, food, etc.); (3) a positive
patient-therapist relationship formed prior to the session
itself; (4) the presence of both a male and female therapist who
"had thorough acquaintance with the phenomena of the drug
through personal experience"; and (5) active therapist
involvement with the patient including role-playing (e.g.,
father, mother). Importantly, these conditions have repeatedly
been found to significantly enhance the personal value of
psychedelic experiences.
In each study, the circumstances under which the session was
conducted were consistent with the purpose and expectations of
the investigator. Consistent with his psychotomimetic
orientation, Freedman' s patients were supervised by a familiar
psychiatrist primarily for the purpose of careful observation and
note-taking. No attempts to relate to the children or personal
experience with the drug were reported. The same applies to
Bender's group although the intent in this case was clearly
therapeutic. She apparently administered LSD as a conventional
daily medication that did not require any special conditions of
preparation, therapist involvement, or setting. However, her
reports are replete with descriptions of spontaneous interactions
between staff and children. Supervision of Bender' s patients was
performed mainly by ward attendants. The adults present in the
sessions conducted by both Rolo and Simmons were also ward
attendants.
The primary purpose of the studies reported by Rolo and
Simmons was explicitly methodological. Both research projects
employed the double-blind method and attempted to follow a
predetermined, uniform procedure during each experimental and
control session. As means of standardizing the sequence of events
and increasing objectivity, both investigators systematically
presented various playing objects, games, and tasks to the child.
Rolo's single patient was encouraged to engage in quite simple,
familiar activities such as throwing a baseball or playing cards.
Simmons, on the other hand, created a far more elaborate series
of game-like situations that were novel and intrinsically
interesting, requiring sustained patient-adult interactions, and
importantly were specifically designed to simulate or elicit
normal social behavior and emotional responsiveness.
A number of probable effects of the physical and psychological
milieu are suggested in these studies that bear a significant
relationship to the investigator' s orientation, on the one hand,
and differences in benefit or outcome, on the other. As indicated
earlier, the expectations of a particular research team seem
highly related to various aspects of both drug regime and
setting. With regard to differential improvement rates, a major
determinant seems to be the degree of active therapist-patient
interactions permitted during the drug-induced state. Secondly,
greater therapeutic benefit seems to occur in congenial settings
offering some opportunity to experience meaningful objects and
interpersonal activities. Finally, psychedelic therapy with
psychotic children seems most effective in natural, flexible
settings that are reasonably free of artificiality, experimental
restrictions on spontaneous behavior, and mechanically
administered procedures. Conversely, barren medical or laboratory
environments seem clearly anti- therapeutic.

RESULTS

As emphasized previously, each of these exploratory studies
suffered major shortcomings either as therapeutic or experimental
undertakings. Almost without exception, the findings reported
consist mainly of observational data obtained during the acute
phase of drug reactivity. The use of pre-treatment baselines
against which to measure change either during or after
psychedelic therapy were generally absent. In most cases,
follow-up data was not obtained. Although caution in interpreting
results is certainly indicated, it should be pointed out that
these limitations are shared by the bulk of research on drug- and
psycho-therapies. Furthermore, objective evaluation of
improvement in severely disturbed children presents unique
problems due to the nature of autistic symptoms, especially the
ubiquity of mutism. Even the few cases not suffering from a
complete absence of speech were untestable by standard
psychological assessment methods.
In their initial study, Bender and her coworkers (1962)
administered the Vineland Maturity Scale at the beginning of
treatment and again three months later. At the followup testing,
ratings were qualitatively higher for all children. In the second
study (Bender, et al., 1963), the Rorschach, Draw-A-Person, and
Bender-Gestalt tests were given to the ten verbally responsive
children on at least two occasions; before treatment and again
after a three to eight month interval. In these aggressive,
overtly psychotic patients, Bender reports that "there were
two major changes observed: (1) There was a decrease in
personalized ideation and a corresponding gain in accuracy of
response; and (2) An inhibition of strongly emotional or
'feeling' reactions to the cards." Other favorable changes
reported included decreases in hallucinations, negativism, and
regressive defenses with a corresponding increase in reality-
contact. Similar types of improvement were found in the older
children treated by Fisher and Castile.
With regard to her major group of young autistic children,
Bender reported significant improvement in speech and verbal
communication:

". . .the vocabularies of several of the children
increased after LSD or UML; several seemed to be attempting
to form words or watched adults carefully as they spoke; many
seemed to comprehend speech for the first time or were able
to communicate their needs... Very few of these changes in
communication had been noted previously in such a large
number of children, and at such a relatively rapid rate"
(1963, p. 91).

Since mutism is a cardinal symptom of autistic children and
probably the major impediment to successful therapy, it is worth
emphasizing that at least temporary speech improvement has been
one of the most frequently reported effects of LSD in the work
conducted thus far. Other communalities include an elevated mood,
less compulsive ritualistic behavior, and increased interaction
with others. All investigators reported some favorable change in
these major areas with the exception of Rolo' s single patient .
Rolo's group abandoned the attempt to estimate improvement since
their judges could not distinguish between LSD and non- LSD
trials. Bender, on the other hand, made the following
observations:

" They appeared flushed, bright eyed, and unusually
interested in the environment... They participated with
increasing eagerness in motility play with adults and other
children. . . They seek positive contacts with adults,
approaching them with face uplifted and bright eyes, and
responding to fondling, affection, etc." (1962, pp. 172-
3). "There is less stereotyped whirling and rhythmic
behavior. . . They became gay, happy, laughing frequently...
Some showed changes in facial expression in appropriate
reactions to situations for the first time" (1963, pp.
90-91).

As indicated earlier, Simmons' patients were subjected to a
uniform sequence of game- like situations that evoked a variety
of measurable responses. During each LSD session and non- LSD
session, a total of 20 specific behavioral measurements were
taken by a recorder observing the patient through a one-way,
screen. The behaviors recorded included physical contact with the
adult present, vocalizations, destructive acts, laughter,
stereotyped movements, and eye-to-eye contact. In contrast to
non-LSD trials, the most pronounced and consistent changes
observed during LSD sessions were: "(1) An increase in
social behaviors manifested by increased eye to face contact and
increased responsiveness to adults, (2) An increase in smiling
and laughing behavior generally considered an indication of a
pleasurable affective state, and (3) a decrease in one form of
non-adaptive behavior demonstrated by a reduction of
self-stimulation."
Considering the wide diversity in these studies, the major
findings of Bender, Fisher and Castile, Freedman, and Simmons are
remarkably similar. Differences in orientation, patient
attributes, drug regime, setting, treatment technique, research
design, etc. seem to affect the frequency and stability of
favorable outcomes (see Table 1). The types of improvement, when
and if they occur, appear to be essentially the same in each
study. In short, when LSD is effective with autistic children, it
is effective in characteristic ways.
The influence of non-drug factors is well illustrated in the
work of Fisher and Castile. Although they optimized the physical
and psychological milieu, their patients were the most severely
disturbed and displayed the greatest variety of symptoms.
Furthermore they made conservative estimates of improvement based
on the extent and stability of favorable changes after treatment
was terminated. In contrast, most of the findings reported by the
other investigators concerned the immediate effects of treatment.
These differences account in part for the relatively modest
improvement rates reported by Fisher and Castile.
The lack of even short-term follow-up data on the majority of
children treated with psychedelic drugs has been a major
limitation of the work reviewed bere. Follow-up information is
particularly crucial because the available evidence strongly
suggests that when used alone, LSD produces only transient
alleviation of symptoms. In order to bring about enduring
improvement, the drug induced state requires active therapist
patient interaction and/or subsequent psychotherapy. In this
connection, Simmons noted that:

" Therapeutic intervention in severely retarded or
regressed children utilizes to a great extent close physical
interaction to which the child must respond. In the usual
state it is often difficult to intrude upon the child because
of a general lack of responsiveness... The results of our
experiments clearly demonstrate changes in exactly these
areas with increased attendance to physical and face contact
with an attending adult and concomitant reduction of
competing self- stimulatory behavior... Thus, two possible
criteria for the successful intervention into autistic
children are met... A third piece of data which must be
considered is the increase in smiling and laughing behavior.
. ." (1966, p. 1207).

The collective work reviewed here supports the main conclusion
reached by Simmons and his co-workers and argues strongly for
more extensive and systematic applications of psychedelic drugs
in the treatment of autistic schizophrenic children: "
LSD-25 appears to offer a useful adjunct to psychotherapy because
of its positive effect in the areas described which are closely
related to the process of psychotherapy."

SUMMARY AND CONCLUSIONS

1. Seven independent studies are reviewed involving a total of
91 austistic schizophrenic children who had been given
psychedelic drugs for therapeutic and/or experimental purposes.
2. The large majority of children treated in these studies
were between six and ten years of age and were completely
refractory to all other forms of treatment.
3. There was only slight indication of any differential
response or benefit as a function of age, diagnosis, duration or
severity or illness.
4. A variety of psychedelic agents, dosage levels, frequency
of administrations, and treatment schedules were employed. The
most effective results were obtained with at least 100 microgram
doses of LSD-25 given daily or weekly over relatively extended
periods of time.
5. Concerning the physical and psychological milieu, greater
therapeutic benefit was related to: (a) the degree of active
therapist involvement with the patient; (b) an opportunity to
experience meaningful objects and interpersonal activities; and
(c) congenial settings that were reasonably free of
artificiality, experimental or medical restructions, and
mechanically administered procedures.
6. The most consistent effects of psychedelic therapy reported
in these studies included: (a) improved speech behavior in
otherwise mute children; (b) increased emotional responsiveness
to other children and adults; (c) an elevation in positive mood
including frequent laughter; and (d) decreases in compulsive
ritualistic behavior.
7. Differences in patient attributes, treatment technique,
research design, and other non- drug factors seemed to effect the
frequency and stability of favorable outcomes. The types of
improvement found were essentially the same in each study.
8. Although each of these studies contained serious
therapeutic and experimental flaws, it was concluded that the
collective findings argue strongly for more extensive
applications of psychedelic drugs in the treatment of austistic
children.